Posted by SLS on August 27, 2000, at 14:47:37
In reply to High Dose of Effexor and Remeron?, posted by PG on August 27, 2000, at 8:52:08
Frome Medscape:
Ask the Experts on . . .
Refractory Depression--------------------------------------------------------------------------------
Question
I need some help for refractory depression in a 54-year-old physician. He has a 6-year history of unremitting depression with suicide ideation. The drugs we tried at full dose are (1) desipramine; (2) venlafaxine; (3) nefazodone, good result but discontinued; (4) amitriptyline; (5) fluoxetine up to 40 mg/day. Reasonably controlled on 60 mg of paroxetine daily, 50 mg of doxepin at night, mirtazapine 45 mg at night, 30 mg of flurazepam at night. He still has recurrences. Should I increase the mirtazapine or the paroxetine? Are there any proven unique drug combinations that may help? He has quite severe sweating from the paroxetine and mirtazapine and a 30-pound weight gain. I have put him on phentermine (30 mg twice a day) to control his appetite and help with his extreme fatigue and lack of concentration. Incidentally, he has fibromyalgia, with a peripheral neuropathy. All test results are negative, including HIV. He has refused ECT.Response
from Thomas A.M. Kramer, MD, 08/15/00
It sounds like an extremely difficult case. It also sounds like you have done a superb job with an extremely difficult patient.
One thing in your description I am curious about. You say that this patient failed venlafaxine at full dose. I am wondering what you mean by "full dose." In extremely treatment-refractory patients, often good responses have been obtained by using venlafaxine at extremely high doses, ie, at 500 mg or greater. I have seen case reports of the use of up to 1000 mg a day in these patients with good result. Obviously, blood pressure must be monitored in these patients, but in the case reports that I have read, they have tolerated this dose reasonably well.Failing that, and to answer your questions more directly, I think you can go up to at least 60 mg on the mirtazapine. Some of the greatest success in treatment-refractory patients has come from combining an SSRI with bupropion and/or mirtazapine. You may want to consider this combination if your patient deteriorates.
Finally, there is a great deal of research that has been published recently and continues to be generated on the combination of antidepressants with atypical antipsychotics, particularly olanzapine. These recent data have suggested that there may be some synergistic effect of the combination of these drugs
poster:SLS
thread:43823
URL: http://www.dr-bob.org/babble/20000822/msgs/43833.html